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Pharmacy Benefits FAQs

Frequently Asked Questions


What happened to my employee's prescription drug coverage on Jan. 1, 2020?

As of Jan. 1, 2020, the pharmacy benefit is now administered by a new pharmacy benefits manager (PBM). The new PBM, OptumRx, is an independent company that has been contracted to provide certain services related to your employee's health plan’s prescription drug coverage.

How does this change affect my employees?

There will be little or no effect for most members. Your employees were sent a new ID card to use starting in 2020. Some members may experience additional changes to their prescription drug coverage on Jan. 1, as part of their health plan’s regular pharmacy benefit updates.

How do they know if a drug coverage change affects them?

If were taking a drug that was affected by any coverage or program changes that took effect on Jan. 1, we mailed them a letter in early November describing the change and actions needed.

Will they receive a new ID card?

They were sent a new ID card in December. They can start using their new card on Jan. 1, 2020 for both medical and pharmacy benefits. They will need to show their new card at the pharmacy when they have their first prescription filled in 2020. In addition, they can access an electronic version of their ID card by logging in to the secured portion of their health plan's website.

Did the drugs covered by their plan change?

For most members, the drugs covered by their plan did not change beyond the minor updates that take place routinely at the beginning of each year. If their coverage is through an employer group that is using a new formulary (list of covered drugs) in 2020, they should have received more information about these changes and what they may mean for them. We sent a letter in November with more details.

Do they have to change the pharmacy they use to fill their prescriptions?

Our previous pharmacy network included almost all the same pharmacies as our new 2020 pharmacy network. There are almost 70,000 pharmacies, including all major chain pharmacies and most independent pharmacies. If, for some reason, a pharmacy they were using is not part of the new network, we sent them a letter in December to inform them and suggested other network pharmacies that were nearby.

They can always use the "Find the Pharmacy" locator to search for 2020 network pharmacies. They should always make sure to check their plan materials for information about specific network information that may apply to their plan.

Are CVS pharmacies still be part of the network?

CVS pharmacies are included in our new national pharmacy network.

Did the price they pay for prescription drugs change?

Their pharmacy benefit is based on tiers. Tiers are the different cost levels they pay for medications. For most members, the drugs you take stayed at their current tier. However, from time to time, some drugs may move to a higher tier. If a drug they’re taking moved to a higher tier on Jan. 1, we sent them a letter to let them know. The price they pay is also determined by their pharmacy benefit, so if that changed in some way, the price they pay may have also changed.

What is a specialty drug?

Specialty prescription drugs treat complex or chronic medical conditions. They may require patient-specific dosing and careful clinical monitoring.

An employee takes a specialty drug. Is there a new specialty pharmacy?

Yes. We have a new specialty pharmacy, BriovaRx, which is a division of the new PBM. If their specialty prescription was being filled by CVS Specialty Pharmacy*—and they had refills remaining—their prescription was transferred to BriovaRx Specialty.

Do they need to take any action regarding their specialty prescriptions?

Existing prescriptions were transferred from CVS Specialty to BriovaRx around Jan. 1, 2020. Current members can call 877-259-9428 to get set up to use BriovaRx.

They use mail service to receive some prescription drugs. Has anything changed for them?

Members who use mail service receive up to a 90-day supply of medications they take regularly. Mail service is now provided by OptumRx Home Delivery. Open prescription refills transferred from CVS Mail Service* to the new home delivery pharmacy around Jan. 1, 2020.

What happened to existing mail-order scripts?

Open prescription refills transferred from CVS Mail Service to OptumRx Home Delivery pharmacy. Some scripts did not transfer (compounds, controlled substances and prescriptions with no refills left). We informed them if they needed a new prescription(s) to continue filling via mail. 

Do they need to take any action regarding their mail-service prescriptions?

Although most prescriptions were transferred, they will need to set up a profile with the new mail-service pharmacy. They can call 855-811-2218 or use the web to set up their profile.

What if they need a new prescription for mail service?

If they need a prescription for mail service, they need to let their doctor's office know that they have a new mail service pharmacy. Their doctor can e-prescribe directly to OptumRx Home Delivery pharmacy, or they can submit a copy of the prescription with a mail service form.

A drug they take required prior authorization. Has anything change for them?

All active prior authorizations (PAs) transferred around Jan. 1 and remain active.

Do they still have access to their pharmacy claims history?

OptumRx loaded one year of historical data for each member. This is available when they log in to My Health Toolkit. For older information, please log into the Caremark website.

What pharmacy information can they find within My Health Toolkit?

The type of information they can find by signing into the secure portion of our website is the same as they can access now, including a drug cost search tool, information on drugs covered by their plan and pharmacy claims history.

Are they still able to get to their pharmacy benefits through My Health Toolkit?

Yes. The first time they use this feature, they will have to create a login. After that, they can access this information by signing into My Health Toolkit.